“We took out fifteen pounds of a dirty, gelatinous looking substance. After which we cut through the fal- lopian tube, and extracted the sac, which weighed sev- en pounds and one half… In five days I visited her, and much to my astonishment found her making up her bed.” (McDowell E. Three cases of extirpation of diseased ovaria. Eclectic Repertory Anal Rev. 1817; 7:242–244.) Terms and definitions
Laparo or lapar (Greek: λ α π α ρ α, λ α π α ρ ο σ) means the soft part of the body between the ribs and the hip; it denotes the flank or loins and the abdominal wall. This term is sometimes used loosely (and incorrectly) in ref- erence to the abdomen in general. Laparotomy therefore means a surgical incision through the flank; less cor- rectly, but more generally, it is an abdominal section at any point to gain access to the peritoneal cavity.
1. History of abdominal surgery
1809 On Christmas morning, Dr. Ephraim McDow-ell (1771–1830) in Danville (Kentucky, USA) successfully removed an ovarian tumor from Mrs. Crawford without anesthetic or antisep- sis. The risk of fatal infection was very high – the operation was bitterly criticized.
1879 Jules Émile Péan (1830–1898) opened the ab- domen of a patient with cancer of the pylorus. The diseased section was cut out; the remain- der was sewn to the duodenum. The patient died 5 days later.
1880 Ludwig Rydyger (1850–1920) carried out the same procedure, but it had been planned in advance; the patient died within 12 hr, of “exhaustion.” 1881 Christian Albert Theodor Billroth (1829–1894)
performed a successful operation (the patient died 4 months later due to the propagation of
the tumor). Two other, fatal operations followed: Billroth was stoned on the streets of Vienna. 1885 Billroth II (pylorus cc): Successful operations
were achieved.
Today, emergency admissions account for 50% of the general surgical work load and abdominal pain is the leading cause of 50% of emergency admissions. It should be noted that 70% of the diagnoses can be made on the basis of the history alone, and 90% of the diagno- ses can be established if the history is supplemented by physical examination. The expensive and complicated diagnostic tests and instrumental procedures often (> 50%) merely confirm the results of the anamnesis and physical examination (!).
Abdominal pain is frequently (35%) ‘aspecific’; it can be caused by viral infections, bacterial gastroenteritis, helminths, irritable bowel syndrome, gynecological dis- eases, psychosomatic pain, abdominal wall pain, iatro- genic peripheral nerve lesion, hernias or radiculopathy. The frequency of acute appendicitis and ileus is 15–17%; they are followed in frequency by urological diseases (6%), cholelithiasis (5%) and colon diverticulum (4%). The frequency of abdominal traumas, malignant dis- eases, peptic ulcer perforation and pancreatitis is 2–3%, while that of rupture of an aorta aneurysm, inflamma- tory bowel disease, gastroenteritis and mesenteric isch- emia is < 1%.
2. Technical background of
laparotomies
Abdominal incisions are based on anatomical prin- ciples.
They must allow adequate access to the abdomen.
They should be capable of being extended if required.
Ideally, muscle fibers should be split rather than cut; nerves should not be divided.
The rectus muscle has a segmental nerve supply. It
can be cut transversally without weakening a dener- vated segment. Above the umbilicus, tendinous in- tersections prevent retraction of the muscle.
3. Basic principles determining
the type of laparotomy
The disease process
The body habitus
The operative exposure and simplicity Previous scars and cosmetic factors
The need for quick entry into the abdominal cavity
4. Recapitulation: Anatomy of
the abdominal wall
From left to right: 1. the linea alba; 2. the linea semilu- naris; 3. the lig. arcuatum; and 4. the abdominal projec- tion of the lig. inguinale. During laparotomy, different anatomic structures are cut in the upper or lower ab- dominal regions at various distances from the midline (anterior vs lateral regions). During a midline incision, the following tissue layers and structures are divided:
the skin,
the superficial fascia (Camper’s),
the deep fascia (Scarpa’s),
the anterior rectus sheath, the rectus abdominis muscle
the posterior rectus sheath down to arcuate line,
the transversal fascia,
the extraperitoneal connective tissue, the peritoneum.
Recapitulation: Important things about nerves
Transverse incision is least likely to injure nerves. The iliohypogastric (ih) and ilioinguinal (ii) nerves
are sensory:
ih injury leads to a loss of sensation in the skin over the mons;
ii injury leads to a loss of sensation in the labia
majora.
Both ih and ii nerves supply the lower fibers of the internal oblique and transverses; if divided, these fi- bers undergo denervation, which can increase the risk of inguinal hernia.
5. Principles of healing of
laparotomy
Patient risk factors that negatively affect wound
healing:
Diabetes and obesity
Poor nutrition
Prior radiation or chemotherapy Age
Alcohol
Ascites and malignancy
Immunosuppression Coughing, retching
Hospital factors that affect wound healing negatively
Long operations
Along period of hospitalization preoperatively Drains through incision
Shaving prior to surgery
Type of suture Closure technique
6. Prevention of wound
complications
The scalpels should not be the same for the skin and
deep incisions.
A scalpel should be used to cut skin and fascia and not diathermy; the infection rate after diathermy is twice as high.
Deep sc. sutures should be avoided, but absorbable
synthetic material (e.g. 4.0 Dexon) may be used sub- cutaneously to decrease tension on the skin.
Use of catgut (for fascia or sc. suturing) should be
avoided.
Contaminated or dirty wounds:
delayed closure,
staples with saline-soaked gauze. Opening of a bacteria-containing organ:
delayed closure,
irrigation of all layers,
monofilament, nonabsorbable suture,
systemic antibiotics 30 min before operation or as
soon as possible, and repeat in a prolonged case.